The patient came to the clinic 03-September-2016 complaining of neck and right upper limb pain for 4 years  with progressing numbness right hand. MRI cervical spine spine performed 01-September-2016 without report and very bad quality, showing as be an intramedullary mass behind C1-2-3.

On examination, the patient had no pain when turning the head to all direction. There is weak right deltoid 3/5, left 4/5, right biceps -4/5, left 4/5, flexion right hand 3/5, left 4/5, extension right hand -3/5, left 3/5, right triceps 4/5, left 5/5. There is weak dorsiflexion right foot -4/5, left 4/5. The deep reflexes were exaggerated in the right side, but no pathologic reflexes. There is no apparent sensory deficit.

The patient was sent for thorough investigations and MRI cervical spine performed 04-September-2016 showing huge meningioma 33x12.7 mm intradural pushing the spinal cord to the left. Spectroscopy was typical for meningioma and the mass was lacking fibers. There is and extension to the right C1-2 foramen reaching the vertebral artery pushing it anterior.

In prone position with the use of IOM ISIS, laminectomy of C2-3 and partial of C1 was achieved. The dura was opened slightly right parallel to the midline. The dumbbell-shaped appearance of the tumor was due to right C2 anterior and posterior rootlets, which were constricting the tumor and they were preserved to the end of surgery. The matrix of the meningioma was the right lateral wall of the dura, which was coagulated and piece-meal resection of the tumor was performed. MEP was troubleshooting and not informative. After the resection of the tumor a tiny piece and the emergence of the right C1 was removed trying during that to preserve the rootlets. Using MultiGen, bipolar motor stimulation of right C2 was achieved with 1.0 V. Motor stimulation of the right side of the spinal cord and a brisk response of the right upper and lower limbs was achieved above the tumor resection area. Irrigation of the area with 1 ampoule Papaverine diluted with 20 ml saline. The dura was closed water-tightly. Routine closure of the wound. The patient was sent to MRI before extubation.

Smooth postoperative recovery. She showed deep paralysis of the right upper and lower limbs, which started to improve over several hours. She was sent to the ICU.

The patient came 03-October-2016 to the clinic walking without aid: The motor function normalized and having numbness left side of the body. The postoperative recovery was amazingly excellent. The wound was clean and she suffered from occipital headache with neck pain.

The patient has huge meningioma compressing the spinal cord. The clinical course is progressive and surgical removal is the only option.

This is the 81st case using the MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine surgery. Click here for reference.

With presence of motor response of the spinal cord above the resected tumor with threshold of 1 V, it tells that in worst scenario, the the paraplegia will be transient.

Nor MRI or CT-scan can give precise real picture of the morphological event. This case is a demonstration, of how DTI still not showing the full picture, and spectroscopy needs more perfection.

Intraoperative neurophysiologic monitoring is a must in this case to avoid catastrophic events.

Intraoperative MRI after resection of tumor can assure the total resection of the tumor and the condition of the spinal cord after removal.

Irrigation with Papaverine is a must to prevent arterial spasm.

In this case ILLICO mini retractor system was of great help.